Minimizing Genital Tract Trauma and Related Pain Following Spontaneous Vaginal Birth

Leah L. Albers, CNM, DrPH; Noelle Borders, CNM, MSN


J Midwifery Womens Health. 2007;52(3):246-253. 

In This Article

Second Stage Pushing: Coached Versus Spontaneous

Most of the research on pushing method has compared directed, coached, or Valsalva pushing (forceful bearing down, closed glottis, and sustained breath holding) with spontaneous or self-paced pushing (non-directed, multiple short pushes, with no sustained breath holding). Studies comparing these two techniques have been primarily concerned with the effect of pushing style on neonatal acid-base status and/or the length of second stage.[15] Some studies have directly addressed the relationship between pushing method and perineal or pelvic floor injury, or have included it in their analyses.[16,17]

Sampselle and Hines[16] reported survey data from 39 first-time mothers who gave birth within the previous year. Eleven women recalled pushing spontaneously and 28 recalled using Valsalva pushing. An intact perineum resulted in 5 of the 11 women who pushed spontaneously and 2 of the 28 women who pushed forcefully (P < .05). Simpson and James[17] randomized 45 nulliparas with epidurals to either coached pushing at complete cervical dilatation, or to a 2-hour rest period at the beginning of second stage, followed by non-Valsalva pushing. Immediate pushing was associated with lower fetal oxygen saturation and 13 of 22 women in this group had perineal lacerations compared with 5 of 23 in the delayed pushing group (P = .01).

Schaffer et al.[18] randomized 128 nulliparas to either coached (Valsalva) or non-coached pushing for second-stage labor to assess the effect on pelvic floor function at 3 months after birth. Only two women per group used epidural analgesia. Three months after birth, all women had pelvic floor and urodynamic studies, including vaginal squeeze tests and coughing against a full bladder. Women who had used Valsalva pushing had less favorable urodynamic indices, indicating potential pelvic floor dysfunction from forceful pushing to effect delivery.

Finally, a secondary analysis from the perineal management trial by Albers et al.[19] assessed risk factors for sutured genital tract trauma in first-time versus other mothers. All women (N = 1176) had spontaneous vaginal births without an episiotomy. Women with sutured obstetric lacerations were more likely to have used Valsalva pushing than women without lacerations (37% vs. 24% of first-time mothers and 26% vs. 15% of other mothers). In first births, where mothers tend to push longer, regression analysis showed that Valsalva pushing in second stage was an independent predictor of childbirth lacerations (RR = 1.65; 95% CI, 1.05-2.59).

These studies indicate that the only apparent advantage of Valsalva pushing is a shorter second stage, which, on occasion, may be desirable. However, expediting delivery by forceful, directed pushing is achieved at the expense of three negative outcomes: reduced oxygenation of the fetus, more frequent trauma to the birth canal, and potential injury to future pelvic floor function.


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